"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

February 10, 2016

The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals about active public health threats. This issue covers the period from 31 January to 6 February 2016 and includes updates on seasonal influenza and Zika virus infection outbreaks.

Seasonal influenza

So far, the 2015–16 influenza season has been characterised by a predominance of influenza A(H1N1)pdm09 viruses, accounting for 67% of sentinel surveillance detections of influenza in the WHO European Region. Compared to A(H3N2) viruses, A(H1N1)pdm09 may cause more severe disease and deaths in adults aged 15–64.

During week 4/2016, 31 of the 50 countries and territories that reported epidemiological data from ILI and ARI surveillance indicated increasing rates, with 34 countries reporting influenza virus detections in specimens from sentinel sources for week 04/2016, indicating increased influenza activity in the WHO European Region as a whole.

Belarus, Greece, Ireland and Malta indicated high-intensity influenza activity, as in the previous week, and Finland, the Russian Federation and Ukraine reported very high activity.

ECDC monitors influenza activity in Europe during the winter season and publishes its report weekly on the Flu News Europe website.

Zika - monitoring global outbreaks

As of 4 February, no autochthonous Zika virus transmission has been reported in the EU.

On 1 February 2016, WHO declared a Public Health Emergency of International Concern (PHEIC) regarding clusters of microcephaly cases and other neurologic disorders in some areas affected by Zika virus.

Since last week, five additional countries or territories have reported laboratory-confirmed autochthonous transmission in the past two months: American Samoa, Samoa, Costa Rica, Jamaica and Tonga. Several Outermost EU regions continue to report autochthonous transmission, namely, Martinique, Guadeloupe, Saint Martin, French Guiana and Curaçao.

September 23, 2015

A sharp rise in cases of chest and throat disease in India is being blamed by doctors on worsening air pollution in the country, which is now home to 13 of the 20 most polluted cities in the world.

According to India’s National Health Profile 2015, there were almost 3.5m reported cases of acute respiratory infection (ARI) last year, a 140,000 increase on the previous year and a 30% increase since 2010.

The number of ARI cases has risen steadily in India over the last 15 years, even when population growth is taken into account. In 2001, less than 2,000 cases per 100,000 people had an ARI. In 2012 the number was 2,600 per 100,000, statistics show.

The rise has occurred despite steady improvements in medical care and nutrition, as well as a shift away from using wood as fuel in rural areas. Together this has mitigated many factors long blamed for the high levels of respiratory diseases in India.

Doctors are blaming the increasing severity of the problem on unprecedented decline in air quality across India.

“Due to the awareness drives conducted about diseases like swine flu and influenza, people have become more aware ... Yet air pollution is playing a major role in [increasing] the numbers of such diseases,” Dr Jugal Kishore, head of community medicine at Delhi’s Safdarjung hospital, told the local India Today news magazine.

Attention to the problem of air pollution in India has so far focused almost exclusively on the capital. One study found that half of Delhi’s 4.4 million schoolchildren would never recover full lung capacity.

But the rest of India has received less attention, though in many cases the problem is almost as acute, or possibly worse. The latest government figures show high numbers of lung and throat infections in the eastern state of West Bengal, the central state of Andhara Pradesh, as well as in tourist favourites Kerala and Rajasthan.

Mumbai also has pollution levels which, though lower than in Delhi, exceed safe limits set by the Indian government many times. Those limits are significantly higher than those set by international experts and western governments.

This summer, some reports suggested that Chennai experience worse pollution than anywhere else in India. Though the data has been challenged, it is clear that the levels of hazardous gases such as carbon monoxide, nitrogen dioxide and ozone, as well as of deadly fine particulates, in the southern city have consistently breached the World Health Organisation’s maximum safe limit.

A major health crisis is unfolding in conflict-ravaged Yemen, where hospitals have been destroyed, health workers killed and critical shortages of food, medical supplies and fuel are causing large-scale suffering , according to the World Health Organization (WHO).

“Urgent action is needed to safeguard health facilities and ensure people caught up in the insecurity have access to health care,” says Dr Ahmed Shadoul, WHO’s Representative to Yemen.

“Yemen’s health system is on the verge of breakdown, and it is only thanks to the heroic efforts of the country’s health workers, the resilience of its brave people and the tireless efforts of national and international humanitarian organizations that any semblance of health care is being provided.”

Key health challenges

From 19 March to 15 June 2015, more than 2800 people have been killed in the conflict, and approximately 12 500 injured, according to Yemen’s Ministry of Health.

Key health challenges include:

• more than 15 million people, including over one million internally displaced person (IDPs), in dire need of health services;

• critical shortages of medicines for diabetes, hypertension and cancer, and essential supplies including trauma kits and blood bags;

• more than 3000 suspected cases of dengue fever;

• 1.8 million–2.5 million children at risk of diarrhoeal diseases and up to 1.3 million children at risk of acute respiratory infections;

• increase in hospital admissions for malnutrition by 150% since March;

• health worker safety under threat, including 5 deaths and 5 injuries, and at least 53 health facilities damaged – including 17 hospitals, as well as the Operations Room of the Ministry of Health in Sana’a, which manages all emergency operations for the entire country;

• more than 20 million people in Yemen lack access to safe drinking-water and sanitation.

WHO and Health Cluster partners have been responding to the Yemen health crisis by providing supplies, services and support to national and regional authorities.

November 28, 2014

With 100-plus deaths daily, pneumonia has emerged as a leading cause of deaths among children under 5 years in Bihar, a survey report said and recommended the government to launch a special drive like the one for polio. The research study funded by Bill and Melinda Gates Foundation in five districts of Bihar along with nine in Uttar Pradesh came out with this startling data.

Shally Awasthi, professor, department of pediatrics in King George's Medical University (KGMU), Lucknow, who headed the survey, told a seminar at AIIMS Patna that 40,480 pneumonia deaths have been reported annually in Bihar.

"If we further break it the statistics would be 100 plus deaths daily and 5 per hour", she said. Annually there are approximately 1.84 million deaths in children under 5 years due to pneumonia in the country out of which Bihar's share is 22 per cent, she said.

The five districts of Bihar where survey was conducted in between July 2013 to May 2014 included Gaya, Darbhanga, Madhubani, Nalanda and Chappra. In UP, the study was done in Lucknow, Gorakhpur, Mahoba, Agra, Meerut, Unnao, Mathura, Moradabad and Banda.

She said pneumonia is mainly caused due to malnutrition, lack of breast feeding, no vaccination and excessive use of bio mass fuel by mother particularly in rural areas.

The seminar was attended by representatives from Unicef, Bill and Melinda Gates Foundation, WHO and health officials of Bihar at AIIMS at Patna.

Drawing attention towards the magnitude of the problem, Awasthi and others emphasized on launching a special drive against pneumonia like the one done successfully for polio. The participants stressed on spreading awareness and dedicated facilities in community health centre against pneumonia.

BANNU: The number of internally displaced people (IDPs) registered with the Fata Disaster Management Authority (FDMA) reached 910,040 on Saturday and those feeling from North Waziristan Agency face health related challenges.

As the registration of the internally displaced persons (IDPs) continued for the sixth day in Peshawar, 4,500 people were added to the list, which according to the FDMA has reached to 80,122 families, among them 235,499 are male and 261,734 are female, and the rest 393,636 are children who are faced with severe health hazards and ailments.

Almost half of that number, mostly children and women, face serious health hazards due to poor hygienic conditions, in addition to severe hot weather which has increased ARI (Acute Respiratory Infection), gastro infections, skin and other water borne diseases.

Hundreds of patients mostly children, women and elderly tribesmen are arriving at hospitals with gastroenteritis, ARI infections and diarrhea infections but further, the hospital conditions and facilities are inadequate to cope with the situation.

Many of the IDPS are complaining that the children are the most affected as many of them are malnourished as well.

Living in highly unhygienic conditions has multiplied their problems and the infection ratio is very high due to poor sanitation.

Yousaf Shah of Mirali, who brought his two children to the Khalifa Gul Nawaz Hospital now run and managed by the army stated that rashes and break outs of the skin have appeared on his children who are also suffering from stomach ailments.

He said that most people are suffering from diseases as they are living in highly congested environment with at least 20 to 25 people living in one room.

Furthermore, he said the drinking water and toilet facilities at the host families houses and schools were really poor and could not cater to their needs.

Akran Wazir from Dattakhel who was visiting the District Headquarters Hospital for treatment had a severe heat stroke, while his children were also suffering from gastro infection.

He said that the people living beyond Miramshah belonged to colder areas and the heat here (at the IDP camps) was beyond tolerance.

Background. No studies have examined the effectiveness of influenza vaccine against ICU admission associated with influenza virus infection among children.

Methods. In 2010-11 and 2011-12, children aged 6 months to 17 years admitted to 21 US pediatric intensive care units (PICUs) with acute severe respiratory illness and testing positive for influenza were enrolled as cases; children who tested negative were PICU controls. Community controls were children without an influenza-related hospitalization, matched to cases by comorbidities and geographic region. Vaccine effectiveness was estimated with logistic regression models.

Results. We analyzed data from 44 cases, 172 PICU controls, and 93 community controls. Eighteen percent of cases, 31% of PICU controls, and 51% of community controls were fully vaccinated. Compared to unvaccinated children, children who were fully vaccinated were 74% (95% CI, 19 to 91%) or 82% (95% CI, 23 to 96%) less likely to be admitted to a PICU for influenza compared to PICU controls or community controls, respectively. Receipt of one dose of vaccine among children for whom two doses were recommended was not protective.

Conclusion. During the 2010-11 and 2011-12 US influenza seasons, influenza vaccination was associated with a three-quarters reduction in the risk of life-threatening influenza illness in children.

March 24, 2014

In new estimates released today, WHO reports that in 2012 around 7 million people died - one in eight of total global deaths – as a result of air pollution exposure. This finding more than doubles previous estimates and confirms that air pollution is now the world’s largest single environmental health risk. Reducing air pollution could save millions of lives.

New estimates

In particular, the new data reveal a stronger link between both indoor and outdoor air pollution exposure and cardiovascular diseases, such as strokes and ischaemic heart disease, as well as between air pollution and cancer. This is in addition to air pollution’s role in the development of respiratory diseases, including acute respiratory infections and chronic obstructive pulmonary diseases.

The new estimates are not only based on more knowledge about the diseases caused by air pollution, but also upon better assessment of human exposure to air pollutants through the use of improved measurements and technology. This has enabled scientists to make a more detailed analysis of health risks from a wider demographic spread that now includes rural as well as urban areas.

Regionally, low- and middle-income countries in the WHO South-East Asia and Western Pacific Regions had the largest air pollution-related burden in 2012, with a total of 3.3 million deaths linked to indoor air pollution and 2.6 million deaths related to outdoor air pollution.

Seven million deaths a year mean 19,178 per day and 799 per hour: 13 per minute.

The 2009 pandemic caused by influenza A(H1N1)pdm09 virus resulted in more than 18 500 reported US deaths and global estimates that were 15-fold higher.1 In contrast to seasonal influenza epidemics, during which elderly persons have the highest risk for hospitalization and death, many critically ill patients during the 2009 H1N1 pandemic were young or middle-aged adults.2 Other notable risk factors were morbid obesity and pregnancy, including the early postpartum period.2

The dominant feature of critical illness during the 2009 H1N1 pandemic was severe acute respiratory distress syndrome (ARDS) that often developed very quickly following presentation to the hospital and frequently was associated with a long and protracted course and high mortality.2

Since 2009, H1N1pdm09 virus has continued to circulate and cause critical illness worldwide, but it has not predominated in the United States until this season, with a corresponding resurgence of influenza-related hospitalizations, critical illness, severe ARDS, and deaths. This year more than 60% of laboratory-confirmed influenza-associated hospitalizations and deaths reported in adults younger than 65 years to date have been attributed to H1N1.3,4 No significant antigenic changes in circulating H1N1pdm09 virus strains compared with vaccine strains have been detected since 2009.

The relative effect on young and middle-aged adults might be partially due to their low influenza vaccine coverage and cross-reactive immunity to H1N1pdm09 virus that elderly individuals have acquired from past exposure to antigenically related viruses.

Based on lessons learned from the 2009 H1N1 pandemic, we offer suggestions for the care and management of H1N1pdm09 patients at risk for critical illness during this influenza season.

February 23, 2014

A rare "polio-like syndrome" has caused paralysis in about 20 children from across California, according to a report released Sunday by physicians in the San Francisco Bay Area.

The children, who are between the ages of 3 and 12, developed what is called acute, or sudden, flaccid paralysis -- weakness or loss of muscle tone resulting from injury or disease of the nerves that stimulate muscles to move.

Although polio has been wiped out across most of the globe, other viruses can injure the spine, causing paralysis, said Dr. Keith Van Haren, author of the case report and a pediatric neurologist at Lucile Packard Children's Hospital, at Stanford University. The children who have been affected seem to have been permanently paralyzed, he said.

Van Haren said these cases suggest there is a possibility of a new infectious polio-like syndrome in California.

The illness is not polio. All the victims had been immunized against polio and tested negative for the presence of the disease, Van Haren explained. And the disease is rare. "It's not an epidemic," he said. "But it is something that is concerning."

The culprit could be a virus strain called enterovirus-68 that has been linked to polio-like outbreaks in children in Asia and Australia, Van Haren said. But not all of the victims tested positive for that virus, so the cause of the disease is still unclear.

Some of the children had respiratory or other illnesses before developing muscle paralysis, but for others muscle weakness was the first symptom.

Van Haren said some victims suddenly developed weakness of one or more limbs within about 48 hours of becoming sick. MRI scans showed worrisome changes in the gray matter of the spinal cord.

To help them more effectively fight the disease, the children were given steroids, intravenous immunoglobulin and or blood plasma exchange -- without improvement, according to the authors of the case report.

How was the mysterious illness discovered? Van Haren said that after he cared for four of five of the first cases that appeared in 2012, he realized the children's illnesses and resulting paralysis were highly unusual. He notified the California Department of Public Health, which has helped monitor the outbreak since.

Van Haren and his team reviewed all five polio-like cases among children whose lab samples had been referred to California's Neurologic and Surveillance Testing Program from August 2012 to July 2013. He has now included the data from about 15 additional cases reported since then, which he'll be presenting at the American Academy of Neurology annual meeting, held April 26 to May 3 in Philadelphia.

Flaccid paralysis -- unlike measles or pediatric flu deaths, for example -- is not considered a disease or condition that must be reported to county or state health departments or national agencies like the U.S. Centers for Disease Control and Prevention.

Because there is no reporting requirement, the scope of the problem is still hard to assess, explained Dr. Carol Glaser, chief of encephalitis and the special investigations section in the California Department of Public Health. "We do not know whether these cases represent an increase in cases over what usually occurs or even if cases are an ongoing or isolated occurrence," she said.

Glaser also pointed out that the California Department of Public Health has not yet identified a common cause for the cases. "At this stage, CDPH has asked health care providers to report any polio-like cases they might identify and send specimens so that we can better assess the situation," she said.

On a national level, the CDC also cannot know for sure whether there are more cases of this polio-like syndrome than they have heard about, or to what event the illness may be appearing in other states. "It's hard to know if five or 20 cases in the course of a year or two are significant," said Jason McDonald, CDC spokesperson. "Acute flaccid paralysis can be the result of a variety of viral and non-viral causes."